010-941-16-1104-LUP-2004-487 Application for Land Use Permit(*Non-shoreland*) o 0
County of Sawyer ,�,
PO Box 676 -Hayward WI 54843
715/634-8288
*Properiy that is not located within 300'of a creek,river or stream or within 1000'of a � �
flowage,lake or pond or does not have any of the above waterbodies located within 1
the property's boundaries. `�
CONSTRUCTTON SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED. fi '
PRINT—USE BLACK INK OR PENCIL �
� ����I"l�� l�cl—G�i$� C�i(/Z(_� SAMG G�. A�
Owner Builder N' �
'�r (J /J c� �Io n p �
Mailing Address Mailing Address O
�a��-li�arc 1-���i S`��S'3 �
City, ate,Zip City,State,Zip �
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Daytime Phone yG�S / ti Daytime Phone \
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Additional Information:
Zone District: � � � �
Lot Dimensions: �!� X d 0 U �
p
Date lot was created: 7 � � Acres: � n
Is there wetland near the proposed structure?If yes,how faz il�C G �
Building Land Use Floadptain.f )Yes (y,}No _�_ :° �
�j New ( )Filling � a�
Addition Dred in Drivewa access off of a Check one fD S
� ) � ) g g Y � )� ao
( )Alteration ( )Grading ( )Private Rd ( )Town Rd. o '�
( )Moving On ( ) ( )County;iwy (�'State Hwy N �
� ) � ) o �
t�
Primary Structure Accessory Building Addition � °
( )Dwelling ( )Garage-attached/detached ( )Deck W
( )Yeaz round ( )#of car stalls ( )Porch =
( )Seasonal �Storage Building ( )Enclosed �
O Frame built on site O Screenhouse O Living room v
( )Modulaz/manufactured ( )Greenhouse ( )Kitchen O �
( )Mobile/manufactured ( )Other ( )Bedroom C
(-)Other primazy structure ( ) ( )Relocate/enlazge ' '
,o �
( ) ( )#of new -C
�) Cf v 2 c ` ��
AdditionalInformation: b� <
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Type of Construction: �
( )Frame ( )I,og ( )Pole/metal ( )Block ( )Concrete �°`
( )Other ,�
ro
Construction Cost:Primary Structure$ � �
Accessory Building:$ Addition:$ � �
m �
Deed:Vol 3�":3 Pg �/`/2 Certified Soil Test# ��'(� °O z
'�:.r��='� ..
CSM:Vol �; Pg;/;;�;,; Lot# /,;i v Sanitary Permit# ��`G�� o, �
Plat Envelope Dr� n� �1
Condo Vol Pg Yeaz Installed�G g0 � �
Aff of ex septic Vol Pg Owner When Installed: " �
Previous office approvals/actions: s \a
. 1` p
Variance:# LUP:# SP:# CUP:# �'G•-C6'] �� b�
Inspection Report:# Change of Zone District: Q\ 1,,�
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,�2 l0(a -
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Describe the construction using these columns. List the dimensions of each structure in a separate
column. List each story, each addition, each alteration in a separate column.
#1 . � la �% o #2. #3. #4.
Size l � ft. wide ft. wide ft. wide ft. wide �
� � ft. long ft. long ft. long ft. long �
Floor area I N y sq. ft. sq. ft. sq. ft. sq. ft.
Hgt. from grade 3 '' to peak I U - i 2 ft. hgt. ft. hgt. ft. hgt.
Stories 1 stories stories stories
# of bedrooms ---
(� Gc ' Rear Lot Line
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_ ._._ _-- ,' ARL APPRoxiH�T�
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, ' No -r To �cA��-
N_� /. _ � � 7 � _ �.__�
Fire Number and Name of Road %/ � 5�`�� S�"�`�� � � z � 1 �
1 . Enter lot dimensions and indicate north by arrow. Sign ture of Owner r u orized Agent:
2. Indicate the location and size of the requested construction � �. �� ' ,
Signature
activities. 1
PrintName: 1�ENf✓�ila L�. ��>J�-� ��r✓��-�r-';;� c- �
3. Also, indicate the location and distance to the well, The above ceRifies that the listed information and intentions are
true and correct., that all work shall be performed in compliance
septic tank and drainfield, wetland areas, lot lines and to the with the requirements of the Sawyer County Zoning Ordinance
and the laws and regulations of the State of Wisconsin, and if
centerline of the road. a�t��9 as ow�er�s� a9e�t, has the permission of the owner(s) to
perform the work requested on this application. The above
personsls hereby give permission for access to the property for
onsite inspection.
Permit fee: $
September 7 , 2004 �/U.G�%l'�'�i��%�Z�
Issue Date Signature of Issuing Agent
September 7 , 2005 50% Rule: Average Road Setback:
Expiration Date
Office Comments:
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